Affordable Care Act Update

Allison RiceDuke AIDS Policy Project

Region 7 -- June 13, 2013

Medicaid Expansion(income up to 133% FPL)

Insurance Marketplace with financial help

(Income 100-400% FPL)

Pre-2010 options(employer, “Old Medicaid,” Medicare, etc.)

Affordable Care Act: The original concept

Medicaid Expansion(income up to 133% FPL)

Insurance Marketplace with financial help

(Income 100-400% FPL)

Pre-2010 options(employer, “Old Medicaid,” Medicare, etc.)

Affordable Care Act: Supreme Court’s Concept

No help for people under 100% FPL*

Insurance Marketplace with financial help

(Income 100-400% FPL)

Pre-2010 options(employer, “Old Medicaid,” Medicare, etc.)

Affordable Care Act: North Carolina’s Reality

*except documented immigrants in US less than 5 years

No Medicaid expansion in 2014

Coming soon: Insurance Marketplace, with subsidies for uninsured people/families with incomes 100-400% FPL

◦ Open enrollment 10/1/2013 – 3/31/2014◦ Coverage begins 1/1/2014

ACA implementation

Empty or Full?

• Employer sponsored insurance

• Medicare• Medicaid• Health Choice

(CHIP)• Ryan White/ADAP

Same or

better

• Insurance Marketplace with subsidies for lower income uninsured

• Free preventive services

• Foster kids keep Medicaid up to age 26

• Medicaid/CHIP: New rules for counting income for (“MAGI”) – based on IRS standards

• Medicare Part D donut hole keeps closing

New

2014 Landscape

• There will still be coverage gaps• Need for wrap-around services that aren’t covered by

insurance

Ryan White & ADAP continue

• Undocumented• Families for whom marketplace insurance is

unaffordable even with subsidies• Married persons who don’t file taxes with spouse• Children in families over CHIP income limit that can’t

qualify for subsidies• Families where a parent has employer-sponsored

insurance that’s deemed affordable, but family coverage is too-expensive

Coverage gaps:

Health Reform & ADAP/Ryan White

Run by Federal Govt.

Open to people* without access to adequate, affordable insurance (public or private)◦ *Except undocumented

“Mandate”: You must have insurance if income is over 133% FPL ($15,282)

Some exemptions; penalty low to start

NC Insurance marketplace: Basics

Must be citizen or legal resident to purchase marketplace insurance

Can’t be eligible for Medicaid, Medicare, other public coverage

Client can’t drop employer-sponsored insurance to get subsidies in marketplace

To get subsidies, must have income 100-400% FPL

Which clients can enroll?

Standardized plans – ◦ Will follow Blue Cross Blue Shield Blue Options plan◦ Comprehensive drug formulary

Essential Health Benefits

Free Preventive Services – ◦ Well woman’s exam, mammogram, immunizations, STI

prevention counseling, smoking screening & cessation, etc.

What will the insurance cover?

• Ambulatory Services• Hospitalization• Maternity & Newborn

Care• Mental

Health/Substance Abuse

• Prescription Drugs

• Emergency Services• Rehabilitative/

Habilitative • Lab Services• Preventive & Wellness

Services & Chronic Disease Management

• Pediatric services

Provider networks

Benefits &

utilization limits

Drug coverage Cost

Plan selection considerations

• Between 100% and 400% FPL• Premium cost: 2% - 9.5% of incomePremium

• Between 100% & 250% FPL• Reduced co-pays, deductibles, etc

Cost sharing reductions

• For all: max ~$6350/year (~$12,700 for families)

• 100-200% FPL 2/3 reduction ~$2117/4233• 200-300% FPL 1/2 reduction ~$3175/6350• 300-400% FPL 1/3 reduction ~$4233/8467

Out of pocket

maximum

Sliding Scale Subsidies

Numbers to remember

100

Under 100 % FPL – no subsidy

Over 100% FPL – help

with premium & cost sharing

133

Over 133% must have “minimum essential

coverage”

250

Under 250% - help with

cost sharing

400

Over 400% can buy

insurance, but no

financial help

• Paid in advance, via reduced premium• Or, person can opt to pay full premium now and take

the credit when taxes are filed.• Credits are “reconciled” at tax time: if overpayment or

underpayment, adjustments made in taxes

Premium Tax

Credit:

• Comes in the form of reductions in co-pays and deductibles so that the plan has a higher value (i.e., it pays for more services).• Example: Person with income between 100 and 150%

FPL ($11,490-$17,235) gets a plan that pays 94% of claims instead of the standard plan that pays 70%

Cost sharing:

How are subsidies paid?

Online & paper applications

Website:◦ Checks

eligibility for Medicaid, CHIP, insurance subsidies

◦ Provides plan comparison

◦ Enrollment online

How will people enroll?

Verification of eligibility

Diagram from NC Institute of Medicine, Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina: Draft Final Report Pending US Supreme Court Decision, p. 64, May 2012

Consumer Assistance

Consumer Assistanc

e

24-hour toll free

call center

Website

Insurance Agents & Brokers

Navigators

Certified Applicatio

n Counselor

Case managers

Friends, family

Navigators• $2.145 million

FQHC:• $4.2 million

Ryan White Part C:• up to $100,000 per

grantee• Capacity development

for • ACA Benefits

Counseling/enrollment• ACA education

Funding for consumer assistance

Navigators• 30 hour online training• Only for funded navigator entities

Certified Application Counselors• Similar online training (probably shorter)• Available to others in community, including

non-funded entities

Training for In-person assisters

Enrollment – What’s the plan?

• Who will help them? What will your role be?• Is there a plan in your larger institution

(hospital, FQHC, etc.)?• How will clients be connected to assistance?

Figure out how your clients will be assisted

• How will they get trained?• How will this work be funded?

Can your staff assist?

• Who else is working on enrollment? • What are the navigator entities? What other

groups/resources exist in your community?

• Not eligible for subsidy, exempt from mandate• Unless other resources/assistance, stay on

Ryan WhiteUnder

100% FPL

• Eligible for subsidy, exempt from mandate• Consider enrollment on case-by-case basis• Possibility of ADAP assistance with costs (2014)

100-133% FPL

• Eligible for subsidy• Subject to mandate• Guidance expected from HRSA on payer of last resort

133% FPL – 400% FPL

Triage – Prioritizing uninsured

Tax based income• Filed taxes?• Filing status

(married must file jointly)

Mechanics of paying for

insurance for clients without bank accounts

Expensive, but not too

expensive employer sponsored insurance

Some Challenges

RW Funds can be used for benefits counseling & enrollment◦ Early Intervention◦ Medical Case Management◦ Non-medical Case Management◦ Health Education/Risk Reduction services◦ Referral for Health Care/Supportive Services

HRSA has put a chart online:◦ http://

hab.hrsa.gov/affordablecareact/outreachenrollment.html

Using Ryan White funds to assist clients in enrollment

Duke Legal Project Health Reform Information site (coming soon)

Hivhealthreform.org Healthcare.gov http://kff.org/health-reform/ http://marketplace.cms.gov/

Information & Resources